Approach For Breast Reconstruction Research Articles

Alginate‐Coated Silicone Implants with Antisolvent‐Crystallized Paclitaxel to Prevent Breast Cancer Recurrence and Reduce Fibrosis

AbstractBreast cancer patients undergoing mastectomy receive silicone‐implant‐based breast reconstruction to mitigate the psychological distress of breast loss, typically in conjunction with adjuvant therapy. However, significant problems remain, such as systemic toxicity from chemotherapy and fibrosis that causes capsular contracture. Here, the development of a silicone implant coated with an alginate gel containing antisolvent‐crystallized paclitaxel (acPTX) is reported. By antisolvent crystallization, the compact formulation of acPTX ensures slow release for long‐term breast cancer recurrence prevention. The mixture of acPTX and the biodegradable alginate gel, which reduces fibrosis, is uniformly coated onto the silicone implant using 3D printed implant‐specific molds based on the shape obtained from 3D scanning. In a breast cancer recurrence mouse model, silicone implants coated with acPTX gel show a long‐term preventive effect compared to gel‐coated implants with commercially available PTX. Furthermore, animal studies using C57BL/6 mice show that alginate‐gel‐coated implants significantly reduce capsule thickness, collagen density, and the number of fibrosis‐related cells around the implant compared to silicone implants. The developed acPTX‐gel‐coated implant presents a promising approach for breast reconstruction in mastectomized breast cancer patients. It provides a novel platform for developing implants with long‐term drug release properties.

The Use of Next Generation Sequencing to Detect Early Implant Infections: The Future of Microbiology and Targeted Antibiotic Treatment

Abstract Goals/Purpose The presence of fluid around foreign bodies, particularly breast implants, is a well-established phenomenon; However scant data exists regarding the composition of this fluid. The difficulty in studying this fluid arises from the lack of safe access to aspirate fluid post-breast augmentation, and by the loss of sterility once fluid exits the body via a drain bulb as traditionally placed during breast reconstruction. Our innovative breast reconstruction approach utilizes a drainless technique with a dual chamber tissue expander (TE) in the pre-pectoral plane, offering a unique avenue to sterilely aspirate peri-implant fluid through a percutaneous drainage port. In this study, we employ Next Generation Sequencing (NGS), utilizing polymerase chain reaction technology, to discern the composition of microbial DNA within peri-prosthetic breast implant fluid. NGS, known for its precision and cost-effectiveness, circumvents the biases inherent in traditional culture methods. By integrating this cutting-edge technology with our breast reconstruction methodology, we sought to study peri-prosthetic breast implant fluid to better understand when implant infections arise and if peri-prosthetic fluid could detect infections before clinical symptoms arise. Methods/Technique This is a single surgeon, prospective study of patients undergoing mastectomy, followed by pre-pectoral, drainless, TE reconstruction. Peri-prosthetic fluid was collected through the TE drainage port in the OR immediately after closure, at 1 week post op, and 3 weeks post op. This fluid was sent for traditional culture and NGS. Patients were observed for signs of infection, antibiotics, return to OR, or implant loss. Results/Complications 33 breasts from 20 patients were included. Patients had a mean age of 50 years. The average length of drainage was 21 days post-operative, with a mean of 131 cc of fluid drained per breast per week. Eight breasts had concern for skin necrosis. In 25 breasts (76%), complete sterility was achieved at the end of the case with no NGS detection of microorganisms in the initial peri-implant fluid sample. However, NGS detected microorganisms in the initial sample in 8 breasts (24%). In 5 of these 8 breasts, microorganisms were cleared by the 1-week sample and another 2 cleared by 3 weeks. The remaining 1 breast continued to have positive NGS and developed clinical signs of infections by week 2, which were not picked up by traditional culture until week 3. One breast with skin necrosis developed a positive NGS at week 3 and clinical signs of infection at week 4. No other clinical infections were seen throughout the study. Conclusion We are one of the first groups to demonstrate the ability to achieve peri-implant sterility at the time of implant insertion in the operating room. This could have significant implications for understanding the necessity of peri-operative antibiotics following breast implant placement. Our investigation into the microbial composition of ostensibly "sterile" peri-prosthetic breast implant fluid provides insight into when microorganisms arise and when they become clinical infections. These promising preliminary results suggests that peri-prosthetic fluid monitoring through Next-Generation Sequencing (NGS) holds significant potential in preemptively detecting implant infections before the onset of clinical symptoms, thereby reducing infection rates. Furthermore, our findings open avenues for targeted antibiotic therapy, contributing to the imperative goal of antibiotic stewardship. Ongoing work is beginning to explore the impact of microorganisms within the fluid on breast capsule formation, as we strive to enhance our understanding of breast implants and infections.

A review of bioengineering techniques applied to breast tissue: Mechanical properties, tissue engineering and finite element analysis.

Female breast cancer was the most prevalent cancer worldwide in 2020, according to the Global Cancer Observatory. As a prophylactic measure or as a treatment, mastectomy and lumpectomy are often performed at women. Following these surgeries, women normally do a breast reconstruction to minimize the impact on their physical appearance and, hence, on their mental health, associated with self-image issues. Nowadays, breast reconstruction is based on autologous tissues or implants, which both have disadvantages, such as volume loss over time or capsular contracture, respectively. Tissue engineering and regenerative medicine can bring better solutions and overcome these current limitations. Even though more knowledge needs to be acquired, the combination of biomaterial scaffolds and autologous cells appears to be a promising approach for breast reconstruction. With the growth and improvement of additive manufacturing, three dimensional (3D) printing has been demonstrating a lot of potential to produce complex scaffolds with high resolution. Natural and synthetic materials have been studied in this context and seeded mainly with adipose derived stem cells (ADSCs) since they have a high capability of differentiation. The scaffold must mimic the environment of the extracellular matrix (ECM) of the native tissue, being a structural support for cells to adhere, proliferate and migrate. Hydrogels (e.g., gelatin, alginate, collagen, and fibrin) have been a biomaterial widely studied for this purpose since their matrix resembles the natural ECM of the native tissues. A powerful tool that can be used in parallel with experimental techniques is finite element (FE) modeling, which can aid the measurement of mechanical properties of either breast tissues or scaffolds. FE models may help in the simulation of the whole breast or scaffold under different conditions, predicting what might happen in real life. Therefore, this review gives an overall summary concerning the human breast, specifically its mechanical properties using experimental and FE analysis, and the tissue engineering approaches to regenerate this particular tissue, along with FE models.

Prepectoral Versus Subpectoral Direct-to-Implant Breast Reconstruction: Evaluation of Patient's Quality of Life and Satisfaction with BREAST-Q.

Over the years, plastic surgery has acquired a central role in the integrated treatment of breast cancer. Direct-to-implant (DTI) reconstruction using the prepectoral approach has emerged as an alternative to reconstruction using the subpectoral technique to overcome the complications arising from this type of surgery resulting as a consequence of muscle elevation. The satisfaction and quality of life of patients undergoing DTI breast reconstruction were evaluated using the BREAST-Q questionnaire, comparing the prepectoral and the subpectoral technique. A single-center cross-sectional study on patients who underwent mastectomy and DTI breast reconstruction at our institution between 2013 and 2021 was conducted. Eighty-one patients were included and mainly divided into two groups based on the surgical procedure: 52 patients undergoing a subpectoral breast reconstruction approach and 29 patients receiving a prepectoral breast reconstruction. In order to assess the quality of life, the postoperative BREAST-Q module was administered electronically to the enrolled patients. Higher scores in BREAST-Q domains were recorded from patients who underwent mastectomy and breast reconstruction with prepectoral technique: psychosocial well-being (P<0.0085), sexual well-being (P<0.0120), physical well-being: lymphoedema (P<0.0001) and satisfaction with information received (P<0.0045). There were further statistically significant differences between the two groups with regard to postoperative complications (p<0.0465) and the need for reoperation (p<0.0275). Patients who underwent DTI breast reconstruction with prepectoral technique were more satisfied in terms of psychosocial, sexual and also physical well-being. These patients also had statistically lower complications and reoperations compared to patients who received breast reconstruction with the subpectoral technique. This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

Preclinical Study of Radiation on Fat Flap Regeneration under Tissue-engineering Chamber: Potential Consequences for Breast Reconstruction.

Twenty-eight female Wistar rats were distributed into three groups: TEC implantation as nonirradiated controls (G1), TEC insertion followed by irradiation 3 weeks later (G2), and irradiation 6 weeks before TEC insertion (G3). G2 and G3 received 33.3 Gy in nine sessions of 3.7 Gy. Growth of the fat flap was monitored via magnetic resonance imaging. At 6 months after implantation, fat flaps and TECs were harvested for analysis. Irradiation did not alter the physicochemical features of poly(lactic-co-glycolic acid)-based TECs. Compared with G1, fat flap growth was significantly reduced by 1.6 times in irradiated G2 and G3 conditions. In G2 and G3, fat flaps consisted of mature viable adipocytes sustained by CD31+ vascular cells. However, 37% (3 of 8) of the G2 irradiated adipose tissues presented a disorganized architecture invaded by connective tissues with inflammatory CD68 + cells, and the presence of fibrosis was observed. Overall, this preclinical study does not reveal any major obstacle to the use of TEC in a radiotherapy context. Although irradiation reduces the growth of fat flap under the TEC by reducing adipogenesis and inducing inconsistent fibrosis, it does not impact flap survival and vascularization. These elements must be taken into account if radiotherapy is proposed before or after TEC-based breast reconstruction.

Anterior-First Approach for Latissimus Dorsi Myocutaneous Flap Breast Reconstruction: A Refined Elevation Method with Detailed Video Instructions.

The latissimus dorsi myocutaneous (LDMC) flap is a preferred flap in breast reconstruction for its wide surface area and volume. Since the flap is situated in the midback area, a lateral decubitus approach is a conventional method. However, proper visualization and access to the thoracodorsal vascular pedicle or muscle insertion is difficult from the lateral approach, causing inefficiency and surgeon fatigue. We propose the 'anterior-first' approach in LDMC flap reconstruction, where the landmark structures are first approached from the supine-anterior position through the mastectomy incision. From January 2014 to December 2020, 48 patients who received immediate breast reconstruction with LDMC flap were included in the study. Patients received reconstruction with the conventional approach (n = 20), or anterior-first approach (n = 28). Demographic factors and the operative outcomes were retrospectively analyzed and compared between the two groups. Compared to the conventional approach group, the anterior-first approach group showed improved efficiency in the duration of total reconstruction (228 versus 330 min, p &lt; 0.001), and flap elevation (139 versus 200 min, p &lt; 0.001). No difference in complication rate and time to drain removal was observed (p = 0.14 and &gt;0.9, respectively). The anterior-first approach for breast reconstruction with LDMC flap provides surgeons with an enhanced surgical exposure and superior ergonomics, leading to a safer and more efficient flap elevation.

ADM-Assisted Implant Based Breast Reconstruction vs. Free Tissue Transfer Breast Reconstruction

Despite in the recent decade, the free tissue transfer has been the gold standard for breast reconstruction and evolving of DIEP, TUG flaps toe the most common used breast reconstruction approach at present time, however the complexity of the procedure, long operative time, donor site comorbidities, long learning curve and subsequently increased cost were always present as downside of this approach (Table 1).

Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction.

We read with interest the article entitled “Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction,” published in the December of 2020 issue by Winocour et al.1 The study demonstrates that the postoperative seroma rate is higher in robotically assisted latissimus dorsi harvest than in the traditional open approach (16% versus 0%; P = 0.034).1 Seroma is reported to be the most common complication at the latissimus dorsi (LD) flap donor site. The reported incidence ranges from 21% to more than 79%.2 Several factors contribute to formation of the seroma: the thermal injury of electrocautery to the tissue, the disruption of lymphatic vessels and capillaries, the release of inflammatory mediators, and the creation of dead space. Various methods have been described to reduce the dead space, such as closed suction drainage, quilting of the skin flaps, application of adhesive tissue glues, infiltration of steroids or sclerosing agents, and reduction of the use of electrocautery.3 In our experience, seroma is a disabling postoperative sequela that increases the risk of wound infection, dehiscence, and skin flap necrosis, thereby compromising the success of reconstruction. In the traditional open approach, harvest of the LD muscle inevitably comprises the lesion of thoracic lymphatic vessels, which contributes in a fundamental way to the supply of the seroma. For this reason, we perform a reverse lymphatic mapping of dorsal region with Patent Blue solution.4 At the start of surgery, we inject intradermally and subcutaneously five bumps of 0.2 mL of blue dye 2.5% (Bleu Patent V 2.5%, 2 mL; Monico SPA, Venezia/Mestre, Italy) into five locations on the lower dorsal region. Referring to Suami’s study,5 we thought to mark the lymphosome that may have been damaged during flap preparation, injecting in five places on the umbilical line every 4 cm, from the incision to the midline (Fig. 1). At the end, when the LD flap is harvested, we proceed to close the interrupted lymphatic vessels, colored by Patent Blue dye (Fig. 2). Quilting sutures and fibrin glue (Evicel; Omrix Biopharmaceutical, Ltd., Tel Hashomer Ramat Gan, Israel) are used to close the dead space. We use two drains in suction, and we ask the patient not to move the arm for 2 weeks. With this approach, patients have been evidenced a lower incidence of seroma. We consider acceptable the modest increase in operating time in exchange for the shorter hospitalization times and reduced drainage times. In no case was there an adverse reaction to the Patent Blue dye. It is our opinion that higher seroma rates could be due not only to the use of electric endothermy and radiation therapy, but also to the difficulty of performing a careful coagulation of lymphatic vessels that are hardly visible if not colored. The use of Patent Blue dye for lymphatic reverse mapping for ligation of damaged lymphatic vessels has proven to be an effective, economical, and reproducible practice. Prospective studies and more case studies are needed to confirm this hypothesis.Fig. 1.: Intraoperative view of the five injections of Patent Blue dye at the level of the dorsal region.Fig. 2.: Damaged lymphatic vessels previously marked with Patent Blue dye.DISCLOSURE The authors have no financial interests to disclose. No funding was received for this communication. Roberta Albanese, MDNicola Zingaretti, MDGlenda Giorgia Caputo, MDEmanuele Rampino Cordaro, MDPier Camillo Parodi, MDClinic of Plastic and Reconstructive SurgeryDepartment of Medical Area (DAME)Academic Hospital of UdineUniversity of Udine

Reply: Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction.

Reply: Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction.

Breast Reconstruction for Cancer Patients in COVID-19 Pandemic.

Breast reconstruction is considered an integral aspect of breast cancer treatment and has a well-known positive effect on quality of life. Surgical treatment of cancer has been delayed until evaluation of local circumstances of coronavirus disease of 2019 (COVID-19), adding to reasons why breast reconstruction procedures may have been delayed.1 In developing countries and middle-income economies, breast reconstruction has had a slow growth; even now, some countries do not cover breast reconstructive surgery, and we were just starting to see progress on the subject in recent years.2 We think breast reconstruction should not be abandoned as an important subject in benefits for cancer patients, even during this pandemic. At our institutions, we continue to offer breast reconstruction surgery, even during the COVID-19 pandemic (Fig. 1). To achieve this, we offer short-recovery surgical procedures to reduce patient exposure to coronavirus. We even try to favor a same-day surgery approach. This could mean direct-to-implant surgery when feasible or tissue expander placement when a second surgery would be required. We also look for options that reduce patient hospital stay, such as enhanced recovery after surgery protocols; combined anesthesia, with local blockades to reduce the effects of intravenous medications (e.g., nausea and vomiting) to favor shorter hospital stays; and oral intubation to contain aerosolization of virus for the protection of the surgical team.3 Immediate reconstruction will favor less exposure to coronavirus, avoiding at least one subsequent surgery and hospitalization.Fig. 1.: Proposed approach for breast reconstruction during the COVID-19 pandemic. DIEP, deep inferior epigastric perforator; SIEA, superficial inferior epigastric artery; SGAP, superior gluteal artery perforator; IGAP, inferior gluteal artery perforator; PAP, profunda artery perforator; TUG, transverse upper gracilis.There have been reports of thrombosis complications secondary to coronavirus infection.4 In this scenario, microsurgery procedures could be delayed until we have more and better knowledge, or at least new data and evidence of perioperative complications in elective microsurgery procedures. When the possibility of radiation was present, or after a shared decision-making approach, we opted for microsurgical free flap reconstruction, a tissue expander would be a better option to delay flap surgery at least 6 months, so we can offer a better safety profile. Offering immediate lymphatic reconstruction would offer higher benefits in these circumstances, to avoid new surgical procedures when possible, in addition to its established benefits.5 Nowadays, coronavirus infection considerations should be part of the shared decision-making process, and first consultation could be performed through virtual online options and three-dimensional models, as well as some follow-up consultations. Breast reconstruction should be considered in breast cancer patients even during the actual COVID-19 pandemic, and time will tell which is the best approach. For now, we should be proactive with caution. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Free-flap breast reconstruction: cost analysis in the Swiss healthcare system

Breast cancer is the most common type of malignancy among women. Mastectomy maintains an essential role in oncological therapy and led to the development of breast reconstruction procedures. The deep inferior epigastric perforator (DIEP) free flap became in the last decade a popular approach for breast reconstruction. Although this procedure is known to be more complex than other techniques, it offers one of the highest patient satisfaction rates. However, the cost-effectiveness of this technique has rarely been assessed; and the real cost coverage by health insurance has never been studied. This study estimated the real cost of immediate DIEP free flap breast reconstruction after unilateral mastectomy and evaluated the cost coverage by healthcare insurers according to the diagnosis-related group (DRG) reimbursement scheme in Switzerland. Medical files of 20 consecutive patients who underwent immediate DIEP free-flap breast reconstruction between 2012 and 2017 were reviewed retrospectively. Billing data according to DRG rates were compared with an estimation of the real cost generated by the procedure. The mean charge according to the DRG model for one-stage DIEP free-flap reconstruction was CHF 29,573 (CHF 19,256–64,741). The mean real estimated cost was CHF 33,416 (CHF 20,633–47,036). Seven different DRG codes were used between 2012 and 2017, each offering a different definition and compensation. The DRG pricing scheme evolves through annual revisions. Progressively, more specific codes were created and used, allowing a better cost coverage for the procedure. Since 2017, the use of the dedicated code J01B has resulted in adequate cost coverage of the procedure. Since it has been widely accepted that DIEP breast reconstruction has advantages such as high patient satisfaction, we encourage the inclusion of this procedure in the reconstructive arsenal of breast cancer centres in Switzerland.

Three-dimensional bioprinting adipose tissue and mammary Organoids feasible for artificial breast structure regeneration

Breast reconstruction is highly recommended for patients subjected to breast surgery considering its impact on mental health. Current approaches include autologous-based tissue flaps, autologous fat grafting and artificial implants, which may cause severe adverse effects, including deformity and morbidity. Recently, tissue engineering methods integrating various biomaterials and diverse stem cells for the purpose of regenrating breast structures have been vastly explored. Nonetheless, regenerating refined individualized structures by traditional tissue engineering methods remain challenging. Involving computer aided design (CAD) of micro-structures, accurate spatiotemporal control of bioink, and selective incorporation of beneficial seed cells and induced factors, three-dimensional (3D) bioprinting technology represents an alternative solution to the encountered drawbacks. This review aims to illustrates the available manufacturing methodologies for 3D bioprinting of breast tissue, various biomaterials suitable for breast tissue regeneration, and previous approaches and designs for breast tissue regeneration. The review highlights the potential of regenerating breast adipose tissue and mammary gland using 3D bioprinting. Of note, to solve the remaining puzzles, we summarized and proposed feasible plans, which may ultimately facilitate 3D bioprinting technology as a promising breast reconstruction approach for clinical applications.

The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis.

The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

A novel approach in breast reconstruction: The extended lateral thoracic flip-over flap combined with loops and lipofilling (ELT FOLL)

The use of the thoracodorsal musculocutaneous flap has been limited to donor site complications, whereas the thoracodorsal fasciocutaneous flap spares the muscle and limits morbidities. Our objective is to describe a new technique of breast reconstruction using an extended lateral thoracic (ELT) flip-over flap combined with loops and lipofilling (ELT FOLL) to achieve better breast remodeling. Between 2013 and 2018, 64 patients underwent breast reconstruction using an ELT FOLL. The flap is designed in an elliptical transverse pattern and extends 2 cm lateral to the back midline up to the breast axis at the level of the inframammary fold. The surgical technique consists of an infiltration and tunnelization of the breast recipient site and surrounding area, deepithelialization of the skin paddle, and additional preparation of the flaps and loops. Liposuction is performed using the power-assisted liposuction and lipofilling technique, and lipofilling is achieved throughout the thoracic cutaneous surface of the reconstructed site, particularly into the lower quadrant of the breast. Among the reconstructions, 73.4% was delayed and 92.2% was unilateral. A fourth of the patients were smokers, and 39.1% received radiotherapy. The total complication rate was 8.7%, the patient's shoulder function was not affected at long term, with the DASH score rising from 6.53 preoperatively to 11.32 at 6 weeks and 7.52 at 6 months. The average operative time was 57 min, and drains were removed at day one after surgery. The ELT FOLL should be considered a simple, safe, and reliable alternative for breast reconstruction.

Breast Reconstruction Combining Lipofilling and Prepectoral Prosthesis after Radiotherapy.

Background:Prosthetic reconstruction in previously irradiated breasts has been associated with a higher risk of complications. Here we describe the surgical and cosmetic outcome of our breast reconstruction process based on primary fat grafting combined with prosthetic placement.Methods:In this multicenter retrospective study, 136 patients who underwent mastectomy and external chest wall radiotherapy between 2014 and 2018 were benefited from chest wall lipofilling and silicone implant placement were chosen. Patients were assessed for skin trophicity, thickness, and mobility and were allowed to undergo several lipofilling sessions before implant placement, if required. No patient had >3 lipofilling sessions. Cosmetic outcome was evaluated by the patient, surgeon, and nurse, using a Likert-type ordinal scale.Results:We included 136 patients: 79 patients (58%) received only 1 session of lipofilling before implant placement, 33 (24.6%) had 2 sessions, and 24 (17.4%) had 3 sessions. The volume of the third lipofilling was significantly higher and the volume of the prosthesis of these patients was significantly lower than those of patients undergoing 1 or 2 lipofillings. Reconstruction failure rate was 2.2% (3 patients had explantation); however, all benefited from prosthesis reconstruction a year after the initial procedures. The average satisfaction score was 4.7 out of 5 as evaluated by patients, 4.8 out of 5 by surgeons, and 4.8 out of 5 by nurses.Conclusions:Primary lipofilling combined with prosthesis placement after radiotherapy is a reconstructive method that yields a satisfactory cosmetic outcome with a low complication rate. Such minimally invasive breast reconstruction approach can be an alternative to flap-based reconstruction.

Indirect versus direct 3D printing of hydrogel scaffolds for adipose tissue regeneration Lana Van Damme, Emilie Briant, Phillip Blondeel, Sandra Van Vlierberghe

There exists a need for an innovative reconstructive approach for breast reconstruction, tackling current drawbacks and limitations present in the clinic. In this respect, adipose tissue engineering could offer a promising alternative. We have previously shown that methacrylamide-functionalized gelatin scaffolds are suitable to support the adhesion of adipose tissue-derived stem cells as well as their subsequent differentiation into the adipogenic lineage. The current paper aims to compare different techniques to produce such scaffolds including direct versus indirect 3D printing. Extrusion-based (direct) 3D printing was compared to indirect 3D printing exploiting a polylactic acid (PLA) sacrificial mould, thereby focussing on the physico-chemical characteristics of the obtained scaffolds. The results indicate that similar properties can be achieved irrespective of the technique applied. It can therefore be concluded that indirect 3D printing could offer some benefits over direct additive manufacturing (AM) as a more complex design can be created while materials that were previously unsuited for direct printing because of limitations associated with their characteristics (e.g. low viscosity), could potentially be applied as starting materials for indirect 3D printing to generate porous constructs with full control over their design.

Abstract 29: Prepectoral Direct-to-Implant Breast Reconstruction: Safety Outcome Endpoints and Delineation of Risk Factors

PURPOSE: Immediate implant-based breast reconstruction is the leading technique for post-mastectomy reconstruction. Although implants are generally placed beneath the pectoralis major muscle, recent developments have allowed for implant placement above the muscle in a prepectoral plane. In fact, prepectoral breast reconstruction has been shown to mitigate complications associated with subpectoral breast reconstruction, including animation deformity and discomfort. Still, few studies have reported long term outcomes of prepectoral implant placement in the context of direct-to-implant (DTI) breast reconstruction. This study aimed to compare safety outcome endpoints between prepectoral and subpectoral DTI reconstruction. We hypothesized that prepectoral DTI breast reconstruction is a safe alternative to subpectoral DTI breast reconstruction. METHODS: Retrospective chart review at a tertiary academic medical institution identified 115 patients who underwent prepectoral DTI reconstruction and 142 patients who underwent subpectoral DTI reconstruction over a 5-year period. Univariate analysis was performed to compare patient characteristics between both cohorts. A penalized logistic regression identified relationships between postoperative complications and covariate variables in each group. RESULTS: A binomial regression model revealed that prepectoral DTI breast reconstruction is associated with lower risk of surgical site infection (p = 0.04) and lower risk of revision (p = 0.01) when compared to subpectoral DTI breast reconstruction. Rates of capsular contracture, explant, skin necrosis, and hematoma were comparable between groups. CONCLUSION: This study compared the safety outcomes and risk factors in prepectoral and subpectoral DTI reconstruction patient cohorts. These findings support the hypothesis that prepectoral DTI breast reconstruction is a safe alternative to subpectoral DTI breast reconstruction, where the analysis revealed that patients who underwent prepectoral DTI reconstruction experienced lower rates of surgical site infection. It is speculated that the significant difference in surgical site infection may be due to decreased procedure time of the prepectoral procedure, or decreased dissection with preservation of the pectoralis major muscle and vascular network. Prepectoral DTI patients also presented with significantly lower rates of revision when compared to subpectoral DTI patients. Ultimately, this study demonstrated that prepectoral DTI breast reconstruction has a favorable safety profile when compared to supbectoral DTI reconstruction. Prospective study of prepectoral DTI is in progress to collect patient reported outcomes to further delineate safety and efficacy of this breast reconstruction approach.

Nipple sparing mastectomy and the evolving direct to implant breast reconstruction.

In this paper, we describe the evolving use of the nipple-sparing mastectomy (NSM) and direct to implant breast reconstruction according to existing literature and our own experience. The surgical method enables superior aesthetic results resembling that of a natural breast while maintaining oncologic safety. Acellular dermal matrix enables direct to implant breast reconstruction by serving as a hammock and can be used with acceptable rates of complications. A successful nipple-sparing mastectomy and direct to implant breast reconstruction approach with acceptable postoperative complication rates relies upon quality of the mastectomy skin flaps and correct patient selection. The surgical method has developed with a rapid pace and expected to evolve further in terms of technical modalities, safety measure and lasting results.

The Evolving Role of Pre-pectoral ADM-assisted Approach in Implant-based Immediate Breast Reconstruction Following Conservative Mastectomy: An Overview of the Literature and Description of Technique.

The recent development of acellular dermal matrix (ADM) devices has enhanced implant-based breast reconstruction surgery following conservative mastectomy for therapeutic and risk-reducing purposes leading to improved aesthetics. In the traditional sub-pectoral approach, coverage of the implant is provided by the pectoral muscles superiorly and the ADM inferiorly. The need to eliminate breast animation, reduce post-operative dysfunctional pain and the risk of capsular contracture, have stimulated surgeons to investigate the feasibility of placing the implant over the pectoralis major muscle with complete coverage with ADM thus inventing a novel pre-pectoral approach. We reviewed the literature regarding this evolving technique of muscle sparing ADM-assisted implant-based immediate breast reconstruction. Also, we describe our technique, and present pictures of the post-operative result. The early reported results of the pre-pectoral breast reconstruction approach are encouraging and confirmed the potential benefits of eliminating breast animation and reducing postoperative pain. However, most of these studies had a small sample size (<100 patients) and were retrospective in nature with a limited follow-up duration and lack of data regarding the objective aesthetic assessment and oncological outcome. Nevertheless, suitable patients undergoing conservative mastectomy and implant-based reconstruction should be offered this option while further evaluation is being performed.

Abstract P3-14-10: Shared decision-making approach in breast reconstruction in a developing country

Abstract Background In Mexico breast cancer is the leading cause of cancer mortality in women. The goal of reconstruction is restoration of patient's quality of life after cancer, including concerns about body image, sexuality, self-esteem and social life. Reconstruction is one of the most important determinants of long-term health. Autologous reconstruction has been found to offer a better satisfaction in the long term, even these findings, a paradigm shift toward implant reconstruction has been described previously. Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together. It takes into account the best clinical evidence available, as well as the patient's values and preferences. In medical treatments where several options have been found, SDM has been a useful tool, increasing patient's satisfaction and better outcomes. Through this process of informing and involving the patient, high-quality decisions that align with patient preferences are achievable. Methods Evaluation of particular case was made, with personalized approach depending on breast cancer stage and mastectomy type planned. On first consultation basic information about different techniques was offered: pros and cons on surgical time, recovery time, long term complications, sensation and physical appearence. We offered a second consultation if the patient wanted to go deeper in the information we presented, or even is she wanted to look out for more information on the internet and other sources. When an abdominal free flap was planned, we saw the patient in a second consultation to review the CT-angio, and to establish the definitive flap option. For risk estimation we used www.brascore.org website, and talk about it with the patient. Then patient and plastic surgeon made decision on breast reconstruction technique. BREAST-Q questionnaries were applied in pre and postoperative setting. Results From 06/2014 to 06/2016 we performed 150 breast reconstructions with this SDM approach with the following techniques: 64% expander, 15% direct to implant, 11% DIEP flap, 6% lattisimus dorsi flap, 3% Becker implant, 1% TRAM flap. BREAST-Q questionnaries showed 100% think breast reconstruction is better than do not reconstruct, and 100% would recommend reconstructive surgery. 91.7% felt included in the decision process. Satisfaction with breast (preoperative vs postoperative) 66.21 vs 81.13, Satisfaction with outcome 85.06, Psychosocial well being 80.75 vs 88.35, Physical well-being 74.92 vs 68.73, Sexual well-being 66.66 vs 72.84, Satisfaction with information 86.86, Satisfaction with surgeon 98.73, Satisfaction with medical staff 96.2. Analysis Implant based reconstruction (82%) was prefered due to: simplicity, less overall risk, and giving more importance to cancer treatment and leaving reconstruction in second place. It could also be a short-term vision regarding benefits, in spite of shared information. Aesthetic improvement of the abdominal area seems to be a factor to decide for autologous abdominal flap among young adult women (7%). Possibility of pregnancy should be considered among young women. In our breast reconstruction program for young women with breast cancer, egg preservation is offered, so abdominal flaps should be delayed after a possible pregnancy. Conclusions We need to encourage SDM in breast reconstruction. We need information systems available to patients prior to breast reconstruction like educational meetings, giving healthcare professionals feedback, giving healthcare professionals learning materials, and using patient decision aids. Shared decisions leads to better outcomes and high patient's satisfaction in breast reconstruction. Citation Format: Maciel-Miranda A, Gutierrez-Zacarias LM, Cabrera-Galeana PA, Bargallo-Rocha E. Shared decision-making approach in breast reconstruction in a developing country [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-10.